38B-291 (2) 284 SOUTH ST BP-2019-0151
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Map:Block:38B-291 CITY OF NORTHAMPTON
Lot: -00t PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Categorv' KITCHEN&BATH RENO BUILDING PERMIT
Permit ft BP-2019-0151
Proiect# JS-2019-000259
Est.Cost:$15000.00
Fee:$97.50 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq.ft.): 4094.64 Owner: CAMPBELL CATHERINE
zoning: URB(100 / Applicant: CAMPBELL CATHERINE
AT: 284 SOUTH ST
Applicant Address: Phone: Insurance:
284 SOUTH ST
NORTHAMPTONMA01060 ISSUED ON:81712018 0:00:00
TO PERFORM THE FOLLOWING WORK.KITCHEN AND BATH RENO AND NEW
WINDOWS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occuoancv signature:
FeeTvpe: Date Paid: Amount:
Building 8/7/20180:00:00 $97.50
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
-- City of Northampton Status of Permit:
Building Department Curb Cut Driveway Permit
212 Main Street Sewer/Septic Availability
:�. Room 100 WetedWall Availability
1 Northampton, MA 01060 Two Sets of Structural Plains
�..� phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWOFAMILYDWELLING
SECTION I -SITE INFORMATION
1.1 Podxwty Address: To
This section to be eornp�l/e/ted by office
—'3+- Map Des LM ri , Unit
Na rl rW11�fi 1 ,
'11A b lo(oo Zone Overlay District
EM Sl District CS District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
o
119 9- 144144-e �..4Foxe a/ovp
Name(PdM) Current Met"Address:
yea_ zao- yea
Telephone
S%
2.z
CCNemC MILrf do Av( l�)WAZ omto
t) L Corton will,Atldress:
1? Swzo 9P71
signeWre Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Olficial Use Only
completed by pemnit apPllmnt
1. Building /t` doo (a)Building Permit Fee
2. Electrical // (b)Estimated Total Cost of
Construction from e
3. Plumbing Building Permit Fee A 7
4. Mechanical(HVAC) �"
5.Fire Protection
6. Total=(1 +2+3+4+5) S 06A Check Number /of(/
This Section For Official tine On
Date
Building Permit Number: Issued:
Signature: 1, 8 Z lat
Building Commksionerllnspecxx of Buildings Data
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING An IMomution Must Be Completed.Permit Can Bo Denied Due To Inornplete Information
Existing Proposed Required by Zoning
This column to be filled in by
p�p Buddin D em
aune
Lot Si. -,yV y1� acCt,3 . oqq_Q•cres
Frontage I Y' c""wWt n t 'v.vl l
Setbacks Front
Side L: R: L: R:
Rear ko&A-- AOc
Building Height A0 C{fr I �O'f cl,n'..�1"1
Bldg.Square Footage 000 /o /000
Open Space Footage _ q
(ue
rvW
M of Parkin Spaces a
Fm:
volmim&Lavation 0
A. Has a Spec' emit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW O YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW ® YES O
IF YES: enter Book Page and/or Document li
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained Q , Date Issued:
C. Do any signs exist on the property? YES (D NO N
IF YES, describe size, type and location: /
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO /0"/
IF YES, describe size, type and location:
E. Will the construction activity,disturb(clearing,grading,excavation,w filling)over i acre or is It part of a common plan
that wAl disturb over t acre? YES ® NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S.DESCRIPTION OFapplicable
New House E] Addition ❑ Replacemen�dom AMaration(s) � Roofing ❑
�{ Or Doors
Accessory Bldg. ❑ Demolition Ww Signs 117] Decks IC7 Siding(1:3] Other[C:0
Brief l) p11 of po Pro
7—
/-J
Wrk,
Alteration of wasting bedroom_Yes_>( No Adding new bedroom Yes X No
Attached Narative Renovating unfinished basement _Yes _ No
Plans Attached Roll -Sheet
ea.If New house and or addition to exled housinit.complete the following
a. Use of building:One Family Two Family Other
b. Number of rooms in each family unit Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
I. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. MassMeck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 fl of wetlands?_Yes No. Is construction vat in 100 yr. floodplain_Yes_No
j. Depth of basement or cellar flaw below finished grade
k. Will building conform to the Building and Zoning regulations? Yes_No.
I. Septic Tank City Sewer_ Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Leo ranI elI / QLDhOy Cao �k
4l as Osmer of the subject
property
reyath
to act on my behaa,in ative rc authodzed by this building permitpplication.
� 7
Signal ^a / n Date
I, ( (l.ul 0 ( OVYI//Y1Z ,as Owner/Authorized
AgenCL. eGare ha the stems end Mfotmation on the foregoing application are true and saturate,to the best of my knowledge
and belief.
Signed under the"inns and penalties of perjury.
C �.0��.l �O✓j'I /
Pdm Nemo
( Signature AOnror/ L,(''�•f�i-L{�-/ Cars
SECTION 6-CONSTRUCTION SERVICES
8.1 Licensed Corrttue0on Suoervlsor. Not Applicable !
Nemo W License Netder
Limnse Number
Address E)pUaOon Date
Signature Telephone
9.Raeletered Nome IMomvament C20jIMS ar. Not Applicable !
Comoam Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT)M.G.L c.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit will result
In the denial of the issuance of the building peril.
Signed Affidavit Attached Yes....... ! No...... !
City of Northampton
/ Massachusetts
Z 5ta7MCNT OF BUZLDZBG ZNSYLKTZOSS .F V
212 pin St[ t • wu,icipu Building
BZthu ., b 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("H1C).
M.G.L.Chapter 142A requires that the"reconstruction, alteration,renovation,repair,modernization, conversion,
improvement, removal,demolition, oroonstmchon of an addition to enypre-existing owneraccupisd building containing
at least one but not more than fourdwelling units.—or to structures which are adjacent to such residents or building"be
done by registered contractors.
Note:If the homeowner has contracted with o carporadon or LLC,that entity must be registered
Type of Work: j&2?110V47yen Est.Cost:/iEe2O
— Address of Work: & V
S' 77pfV f7lL%ti 44'4 Zl11 M6
— Date of Permit Application:
I hereby certify that
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_lob under$1,000.00
Owner obtaining own permit(explain):
_Building not owner-occupied
_Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hemX apply for a building permit as the agent of the owner:
Date Contractor Name HIC Registration No.
OR:
CNotwithstanding the above h by appl for building permit as the owner of the above property:
DateOwn arae and Signature
City of Northampton
+" Massachusetts
A+ �
c
INTAR3 S OF BOIL X.i ifti.TIONB
i
\ Y1'! Nein Stsa�t Non 010 9uildi,g =�
Ne[Cheyton, NA 01060 cT
�
Massachusetts Residential Building Code
Section I I O.R5.1.2
Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,
on which there is, or is intended to be, a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures.A person who constructs more than one
home in a two-year period shall not be considered a homeowner.
Section 110.R5.1.3.1
Any homeowner perforating work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.R5,provided that if a homeowner engages a person(s)
for hire to do such work,then such homeowner shall act as supervisor.
Such homeowner shall submit to the Building Official,on a form acceptable to the Building
Official,that he/she shall be responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to
time,during and upon completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation)and Chapter 153
(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts
General Laws Annotated,you may be liable for person(s)you hire to perform work for you
under this permit.
City of Northampton
�o
-f Massachusetts s
r
ILRAR1fffirT OF BpILDIAG ZASPECZZOAB �
212 1 n St t -1 Lips euildir,
asV
aortne.pmn, b 01060 1 ce
Abri s Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a property licensed solid waste disposal facility,as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
(( Ilse print house number and scree name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
635 tw ko,)AmNYi 2d, "aydm DIo3(o
(Company Name ano Add s)
Signat of e it App' t or Owner Date
If, for any reason, the debris will not be disposed of as indicated,the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The CoHemonweahh of Massachusetts
Depart»tent of IndusirrialAccidents
I Congress Simi,suite 100
Boston,MA 02114-2017
www.m¢csgov/dia
WWorkers'Compensation Insurance Affidavit:Buiklers/Contractors/Electriciona/Plumbers.
TO HE FILED WITH THE PERMITTING AUTHORITY.
p (leantinkniago Plene Print LeAbly
Name(Busmss/OrgamatioMndividual):�t�
Address: ';�.s I/ S61)4/am/
rT T
City/State/Zip: 4,10 A l)l 1)J"✓i7-Piv Phone#: LI, 3 .3::�O - y 9-2-
Are
Art Yso as rm,%W.Cbeek Ye aPPmPrWe baa:
Type of project(required):
I I«neem P".WA emPloYe mull W.,woiitre).' 7. ❑New construction
x.❑lemawle pmpriemr«pmmershipaM havememployws waking firmein 8. ❑Remodeling
mY apaPby.(Howokers'c immaree resound]
39. ❑Demolition
a.❑I am a harvow«r aM win be Mn�wnt«olors a encore!ell work an my pmpeny. f will 10❑Building addition
emwetha ell mabxtasaderhave waters'campmsmiov imivuee«are sole 11.0 Electrical repairs or additions
popielon wiN memployas. 12.❑Plumbing repairs or additions
5 Iran a general oa nowso end I have hired Ne subcmhacmn Iimd ou dm snow sleet
Tnese.m uaaaamanavemryloyeesam pare w«ken'cmry inva« 1 13.QRoofrepairs
b.❑We erea arxwenon aM its oamas bareexxots tk'rnghtofexerrylion per MGL c. 14.00ther
152.41(41 sa we lave ro ernmloyees.[No w«kam'eonp hamwme nx,asd.l
'Am appixanr Net cbee lux al naw fill ow the cion below aw %Nair woken'aans+maanan policy afomm�on
t Hommwrers who submit Nu efidsvit indicaing a"ere dam al w«k and Nm hire outride coarecmrs n submit arew andrvit iMiutmg such
tConunroe that sack on,box n growled on adtlnusal s showing rhe none oftle sibcanhrer«s ux,sere wheam«rat!how atonies have
e�ryloyees. If Ne wbaunbam«s have emplgaa,rley n provide Nab waken'wiry polity number.
l am an enW oyer&&Is preluding wor*m'rompmoaon insumwefm my efployees Blow is the policy andlob site
Information.
Insurance Company Name:
Policy k or Self-ins.Lic.d: Expiration Date:
Job Site Address: City/State/'Lip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MOL c 152,§25A is a criminal violation punishable by a fine up to 51,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under th pewaal/eJsyfJperjury that Ike information provided about Is one and correct,
Silmatum, /L/t Date:
Phone#, Z—
Official use only. Do not write In this area,M be completed by city or town o,91cid
City or Tows: Permft/Lleense II
Inning Authority(circle one):
1.Board of Health 2.Building Department 3.Chyffown Clerk 4.Electrical Inspector 5.Plumbing Inspector
G Other
Contact Person: Phone a:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employersto provide workers'compensation for their employees.
Pursuant to this statute,an enimloyee is defined as"...every person in the service of mother under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee ofm individual,partnership,association or other legal entity,employing employees. However,the
owner of a dwelling house having not more than three apamnents and who resides therein,or the occupmlt of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed in be an employer."
MGL chapter 152,§25C(6)also stores that`every state or local licensing agency shag withhold the issuance or
renewal of a license or penult to operate a business or M construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states'Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy
is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned M the city or town
that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you
have any questions regarding the law or ifyou are required to obtain a workers'compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town O111cials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has w contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that
must submit multiple perrnit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). A copy ofthe affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year.Where a home owner o titian is obtaining a license or permit not related to any business
or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this
affidavit
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
w .mass.gov/dia
Form Reused W-23-15
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant O this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shal I not because of such employment he deemed to be an employer."
MGL chapter 152,§25C(6)also slates that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.-
Additionally,MGL chapter 152,§25C(7)states`Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented in the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the bases that apply O your situation and,if
necessary,supply sub-ommuctor(a)morsels),addresses)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)m Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are rpt required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. He advised that this affidavit may be submitted O the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure O sign and date the affidavit. The affidavit should
be returned O the city or Own thin the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required O obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Offkish
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you O fill out in the event the Office of Investigations has b contact you regarding the applicant.
Please be sure O fill in the pemmitilicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/icense applications in any given year,need only submit one affidavit indicating curent
policy information(if necessary)and undo"Job Site Address"the applicant should write"all locations in_(city or
Own).^A copy of the affidavit that has been officially stamped or marked by the city or Own may be provided O the
applicant as proof that a valid affidavit is on file fm future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related O any business or commercial venture
(i.e.a dog license or permit O bum leaves etc.)said person is NOT required O complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 W W W.mass.gov/dia